Author affiliations

2 University of North Carolina School of Medicine, Chapel Hill, NC, USA

3 University of North Carolina Center for Health Promotion and Disease Prevention, Chapel Hill, NC, USA

4 The Odum Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

5 Department of Family Medicine, University of North Carolina School of Medicine, and Public Health Leadership Program, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

This study used focus groups to pilot and evaluate a new nutrition label format and
refine the label design. Physical activity equivalent labels present calorie information
in terms of the amount of physical activity that would be required to expend the calories
in a specified food item.

Methods

Three focus groups with a total of twenty participants discussed food choices and
nutrition labeling. They provided information on comprehension, usability and acceptability
of the label. A systematic coding process was used to apply descriptive codes to the
data and to identify emerging themes and attitudes.

Results

Participants in all three groups were able to comprehend the label format. Discussion
about label format focused on issues including gender of the depicted figure, physical
fitness of the figure, preference for walking or running labels, and preference for
information in miles or minutes. Feedback from earlier focus groups was used to refine
the labels in an iterative process.

Conclusions

In contrast to calorie labels, participants shown physical activity labels asked and
answered, “How does this label apply to me?” This shift toward personalized understanding
may indicate that physical activity labels offer an advantage over currently available
nutrition labels.

Keywords:

Introduction

Calorie labeling is one of many policy approaches proposed to address the high prevalence
of overweight and obesity in the United States [1-3]. Current strategies in calorie labeling include efforts mainly to increase the visibility
of labels at the point of purchase. The Patient Protection and Affordable Care Act
of 2010 requires that all chain restaurants with 20 or more locations begin to list
the calorie information in the foods and beverages they serve. This new legislation
builds upon efforts already underway in some states to give consumers more information
about the foods they purchase away from home [4]. However, this strategy does not have strong empirical justification. Two systematic
reviews conducted in 2008 [5] and 2011 [6] identified six [7-10] and seven [11-16] studies, respectively, that evaluated the effects of calorie labels on consumer choice.
Both reviews found only weak, inconsistent evidence that calorie menu labels lead
consumers to make lower-calorie food choices [5,6].

Since more visible calorie labels may not be sufficient to influence choice, another
strategy may be improving the usability of calorie labels. Specifically, labels that
frame nutritional information in more familiar and tangible ways may be easier to
understand and have greater potential to influence choice than those that provide
only caloric data [17]. We designed and tested understanding and acceptability of labels that quantified
calorie information in terms of energy balance; the labels depicted how much physical
activity would be required to expend the calories in the food. The labels employed
an iconographic design rather than text or text with graphics used in other studies
[18,19]. The purpose of this study was to assess consumer comprehension of an energy balance
label and evaluate the potential for such a label to influence consumer choice.

Background

Health advocates, government regulators and the food industry are working on multiple
approaches to increase visibility and usability of nutrition labels. Several strategies
being put into practice include calorie menu labels, front-of-the-pack nutrition labels
on prepackaged foods in grocery stores, and universal symbols designating healthy
foods. Research on nutrition label use and understanding indicates that both vary
considerably among different demographics [20]. In particular, consumers have difficulty contextualizing individual food choices
within a total diet [21-24]. Even when nutrition information is available, consumers may value variables like
taste and cravings more highly, and probably do not use nutritional information explicitly
in most food choices [23]. Furthermore, even consumers concerned with nutrition may lack the self-control required
to make the individual healthy choices necessary to achieve lifestyle change [21].

A few publications have suggested calorie labels with a physical activity equivalent
might help consumers make lower calorie choices [17,21], and two studies have quantitatively assessed acceptability of a physical activity
label format [19,25]. Bleich and Pollack found respondents to be equally divided in their preference for
standard calorie labels, physical activity equivalent labels and percentage of total
daily calories [25]. Fitch et al. piloted a physical activity equivalent label beside calorie information
and found that a majority of participants preferred calorie information [19]. One study showed low-income adolescents purchased fewer sugar-sweetened beverages
when exposed to physical activity equivalent labels [18].

Introducing an iconographic label requires special attention to comprehension and
interpretation. Qualitative studies of pharmaceutical warning labels, for example,
have shown that common interpretation of labels differs from what the label designers
intend to convey [26,27]. Qualitative study of physical activity nutrition labels is limited. Van Kleef et
al. conducted a relatively large, multi-country focus group study assessing consumer
understanding of different formats and testing comprehension and usability of different
designs [28]. They found that European consumers preferred other types of labels to exercise labels
as they found the labels “demotivating and patronising [28].” Though consumers understood multiple label formats, van Kleef, et al. noted participants
had difficulty using calorie information to contextualize individual food choices
in overall daily diet [28]. Specifically, users were not sure of their personal daily caloric needs even when
prompted with general information about daily caloric needs [28].

Methods

Study design

We used focus groups to explore preference regarding various label designs, gauge
understanding of their content, and assess their potential for influencing food decisions.
We chose to field three focus groups as three sessions allowed us to modify the questions
and further develop the labels. Study procedures and the focus group guide received
approval from the Institutional Review Board (IRB) at the University of North Carolina
at Chapel Hill (UNC). We received funding through the University Research Council
at UNC.

Study location and participants

We conducted three focus groups in Chapel Hill, North Carolina. The site provided
good access to a socially, ethnically and demographically diverse population.

Participants were recruited through convenience sampling. We contacted healthy volunteers
from an IRB-approved list of previous research participants maintained by one investigator.
We also sent campus-wide invitational emails to UNC students, faculty and staff, and
posted flyers at the UNC Family Medicine Center, the UNC Clinical and Translational
Research Center and community locations including grocery stores, gyms and churches.

To qualify, participants had to be 25 years or older in order to get feedback from
participants who had more substantial experience shopping in grocery stores and eating
at quick-service restaurants. Participants had to have shopped in a grocery store
in the past month and purchased food from a restaurant in the past two weeks. Exclusion
criteria included living in a dormitory, non-English speaking and prior special training
in nutrition. A questionnaire administered by phone was used to establish eligibility.

We had eight participants in the first focus group session and six participants in
the second and third sessions. All participants who arrived for the focus group received
a $20 gift card, and we served lunch to participants.

Focus group discussions

The focus groups were facilitated by two investigators with one investigator acting
as moderator and one other observing and taking detailed notes. The moderator’s guide
was developed through collaboration of the study investigators, who sought additional
feedback from colleagues with expertise in qualitative research methods (Appendix
1). On arrival, participants completed a questionnaire on demographic information
and the Newest Vital Sign, a rapid health literacy assessment [29].

Focus group discussions lasted a total of 90 minutes and were held at midday on a
weekend. After an icebreaker, participants were asked to describe how they make decisions
about which foods to choose, and whether they pay attention to nutrition or healthfulness
of their diets. They then were asked specifically to explain their rationale for making
a food choice in a quick-service restaurant.

We then offered participants a choice of sandwiches and beverages for lunch. Calorie
labels in several formats (Figure 1) were displayed via PowerPoint giving caloric information about the sandwiches and
beverages being served for lunch. By providing labels for the food available at the
focus group, we did not intend to influence participant choices or eating with the
labels, but rather to make the labels easy to relate to and contextually appropriate.
We asked participants to compare physical activity labels with a label stating the
number of calories and their contribution to the recommended daily allowance. Participants
were asked to describe what each of the label formats meant. They were also asked
how they might change the label. In the context of the discussion on label refinements,
participants were shown iterations of labels with slight variations, for example expressing
the amount of physical activity in mileage rather than time, changing the picture
on the label, changing the font, and altering the wording (Figure 1). Feedback from prior focus group discussions was used to adapt the label design
for the second and third focus groups.

Next, participants were asked whether and how they thought the labels might influence
their food choices when at a quick-service restaurant. They were then asked to talk
about the potential role for these labels for prepackaged food products like cereal,
and whether they would use them. Finally, participants had the opportunity to talk
about any food labeling issues we had not covered in the focus groups.

Label design

We designed a variety of menu labels in consultation with experts in nutrition and
medical illustration. We refined the labels in an iterative process, using feedback
from early focus groups to guide label development throughout the study. Many variables
including body weight, gender, age and basal metabolic rate affect energy expenditure
for individuals. Since we sought to produce a universally applicable label, we simplified
by excluding some of these variables. To calculate average energy expenditure for
labels depicting running or walking, we used an average body weight of 160 pounds.
We used an energy expenditure chart that listed estimated calories burned by activity
and body weight [30]. For labels depicting walking, we used the energy expenditure of a 160 pound adult
walking at a rate of 30 minutes per mile (3.2 kcal/min). For running, we used the
energy expenditure of a 160 pound adult running at a rate of 10 minutes per mile (12.8
kcal/min). To determine the number of minutes required to burn off calories in a food
item, we divided the total calories in the item by the energy expenditure rate. To
calculate the number of miles that would be required to expend the calories in a food
item, we divided the total time required by the running or walking pace. Sample calculations
are included (Appendix 2). We obtained information on the caloric content of food
and beverage items from the company websites [31,32].

Using feedback from prior groups, we were able to adapt the labels for the second
and third groups to meet participant preferences. Each set of labels is included (Figure 1).

Analysis

Focus group conversations were recorded using a digital voice recorder and transcribed
into a Microsoft Word file. Transcripts were compared with detailed notes taken by
the assistant moderator during the sessions to verify their accuracy and clarify any
instances where the transcriber was not able to identify the speaker. The moderator
and assistant moderator reviewed the transcripts together.

Once the transcripts were finalized, we used ATLAS.ti Qualitative Data Analysis software
in consultation with a qualitative data analysis expert who did not take part in the
planning or focus groups. We systematically coded the data using descriptive codes
and identified emerging themes and attitudes. We used representative verbatim statements
in our analysis. Quantitative data including group demographic characteristics were
analyzed in Microsoft Excel.

Results

Thirty-eight potential participants were contacted for the study and 34 met inclusion
and exclusion criteria. We fielded three focus groups with eight participants in the
first group and six in each of the subsequent groups. Over half (65%) of participants
were female and 45% were white (Table 1). More than half (65%) of participants lived with a significant other, less than
half (35%) lived with children, and the majority of participants (90%) had adequate
health literacy (Table 2).

Food choices and nutritional information

Participants described a number of factors influencing their food choices including
cravings, past experience with particular foods, price and nutrition or health concerns.
Relating to nutrition, participants categorized healthfulness of foods in multiple
ways including how fat and calorie contents related to their dietary goals, whether
foods were natural or organic, and how many ingredients they had. Some used nutrition
labels to look for sugar or sodium content. For example, one participant commented,
“I tend to look not only at the sodium content, because it’s so high, [but also] at
the sugar content. That can be helpful when I have wanted to lose a little weight
and I was stuck.” Participants also reported that current nutrition label formats
are often confusing. Common concerns include inability to reconcile individual food
items in a daily dietary plan, specific confusion about the 2000 calorie daily diet
that appears on many nutrition labels, and how to use labels to identify healthy foods.
In one session, participants said that they like summary information like a green
check or healthy heart that appears on some labels, but participants in that group
and in others said they do not always trust companies to be honest about what foods
are healthy. Several participants said they had seen “healthy” symbols attached to
items they did not consider healthy. One person said, “I don’t [like the heart healthy
label]. It might be healthy, but there’s a bunch of sugar and there’s a bunch of sodium.
I would rather just have [information on] calories.”

In addition to questions of trust, participants said emotions like guilt, reward,
unhappiness, defeat, burnout and nostalgia influence their food choices. For some,
visiting a fast food restaurant can be a reward and cause them to disregard concerns
about healthfulness. One participant said, “People think, ‘I deserve it today. I worked
harder, I did something or I had more stress.’ Food is often used as a reward. You
may look at it like, it’s gonna cost me a few extra calories, it’s gonna to cost me
20 more minutes here, but I’m worth it today.” More frequently, participants voiced
guilt, unhappiness, defeat and burnout led them to eat things they knew to be unhealthy.
“I feel less guilty when I try harder [to eat healthy] . . . But if I’m putting my
all into it—I’m not even really trying to be a health freak—I’ll be unhappy. You know,
every little thing you put in your mouth, everything you drink. I mean, it’ll just
be too much. You can’t spend your whole life worrying about every little detail. Most
people don’t even have that much time.”

Participant understanding of labels

In all three focus groups, participants were able to verbally interpret iconographic
labels. One participant put it this way: “To go back to zero, as if you’ve never had
anything, as if you’d never eaten you have to walk this amount of time to burn it
off.” As another participant put it, “It means you are going to have to do that much
exercise to burn the calories you just ate.” One participant had an alternative interpretation:
“Another way of looking at it would be that the Big Mac, with 540 calories, would
be equivalent of providing you enough energy to walk 167 minutes.”

Though they were comfortable with the basic meaning of the labels, participants had
questions about the activity depicted, the gender of the figure, the pace of walking
or running depicted, and the apparent physical fitness of the figure compared to their
own. All three focus groups devoted significant time and analysis to the personal
applicability of the labels. One group was concerned with whether the labels would
apply to children or physically disabled individuals. In another group, several participants
debated whether the walking pace depicted should be for the average American, or only
those who exercise.

The research team used details of the discussion and feedback from each group to develop
labels to be tested with subsequent groups. However, the shift in conversation from
calories as an abstract concept to personalized fitness assessment in relation to
a label was perhaps more important. When interpreting numeric calorie labels, participants
understood they applied to a particular item and even ranked items based on the label
as “bad, good, better” in order of descending calorie count. Physical activity labels
helped participants apply caloric information to their lives and thus their food choices.
“What’s interesting to me is there’s only 60 calories between the top and the bottom
sandwich, [but] the difference in the amount of exercise is significant. I mean it’s
almost 20 minutes. To me, that’s a big difference. So you can think I might say gosh
for just 60 calories less I can do 20 minutes less of exercise. So it would help inform
my choice, I think.”

More tellingly, when presented with physical activity labels, each of the groups began
a discussion of whether the labels were personally applicable and how they might be
modified to apply to the average American. For example, several groups thought labels
designed with information for an average weight of 160 pounds could be misleading
or unrealistic and would need to be clarified. “Let’s just say that you show someone
this nutrition label, would it have that disclaimer at the bottom that this is based
on a 160 pound adult? Because that might not be me. [It should be there.] That way,
I can calculate maybe my own number based on my weight.” The change in focus itself
indicates that participants regarded physical activity labels differently.

Participant preferences for label types

In designing the labels, we expected that more participants would identify with icons
that depicted walking than those that depicted running. Participants said that walking
is an activity that more people can do, so people may find the information more applicable
to their lives. One participant expressed, “I would prefer walking only because the
average person could walk. . . But running, everybody’s not going to run. So they’re
going to look at it and be like whatever. I’m gonna be like, I’m not running, but
I’ll eat this Big Mac.” Though it was a minority opinion, two participants said that,
because they found the idea of running more intimidating, a running label might be
more influential. “If your attempt here is to sound a warning that if you eat a Big
Mac, here’s how you’re going to have to pay for it, [the running label] is more intimidating.
It might dissuade you from having a Big Mac and get you to have a turkey sandwich
in place of it.”

While depictions of walking were preferred over running depictions, participants were
split on their preferences for information on mileage versus information on time of
exercise required. Some said that they thought mileage was discouraging: “I think
when you look at miles, it just seems like so much.” Others said they thought miles
were a less common frame of reference. For example, one person commented, “We all
understand what a minute is, but we may not understand what a mile is.” However, several
participants preferred miles because people could move at their preferred pace and
choose to walk or run.

Unintended effects of labels

Participants reported that they might find the labels discouraging because they would
not be able to carry out a particular physical activity, because the depicted activity
is more than they do habitually, or because the time to burn off an item is so great
that it is not worth doing exercise at all. Two groups also discussed whether the
labels implied that people need to exercise sufficiently to account for all of the
calories they consume. Some group members thought they should exercise to burn the
calories they consume while others were able to articulate a more accurate understanding
of daily caloric needs and basal metabolic rate. In general, as in the following quote,
people said that they found the topic somewhat confusing. “You’re eating calories
every day whether or not you exercise or not, so how many do you eat a day, and how
many do you really need to burn off? That’s something that I don’t understand.”

Discussion

To our knowledge, this is the first qualitative study assessing in-depth consumer
understanding of a label that presents calories in terms of a physical activity equivalent.
Our study provides a foundation for further development and testing of such labels
in future research.

Calorie labels and point-of-purchase menu labeling have the potential to influence
consumer choice provided that consumers value the nutritional content of what they
eat and have the literacy and numeracy skills to understand and utilize the information.
Stated differently, nutrition label efficacy depends on relevance and comprehension.
The Affordable Care Act mandated implementation of calorie menu labels as one strategy
to help reduce the prevalence of overweight and obesity. Current evidence suggests
calorie menu labels are insufficient to achieve this goal [5,6], which may be a problem of relevance, comprehension or both.

A functional label format must overcome some of the barriers that limit effectiveness
of current labeling strategies. Issues include problems with consumer literacy and
numeracy as well as label accuracy, applicability and accessibility. Our labels couple
a picture of a physical activity with minutes, hours or miles. A user should “read”
the label as, “You would need to walk for 90 minutes to burn off the calories in this
food item.” In each of the focus groups, participants accurately verbalized understanding
of the labels.

Moreover, in contrast to calorie labels, participants shown physical activity labels
asked and answered, “How does this label apply to me?” The fact that this question
became a focus of discussion in all three groups is perhaps the most robust evidence
from this study. If physical activity labels more effectively prompt users to consider
how dietary choices affect them than currently available calorie labels, they may
have greater potential to influence choice.

Details of the physical activity label were significant to participants because they
compared the walking pace and metabolic rate used to calculate the label to their
own. While it is important that users find the labels personally applicable, accuracy
of the physical activity equivalent for an individual is actually less critical. As
long as the labels accurately portray the difference between caloric content of various
food items, consumers can use that information to make a choice. Prompting participation
in physical activity would be an unintended, if welcome, consequence.

In addition to misinterpreting the meaning of our labels, participants may also be
confused about what the labels imply about the recommended balance of diet and exercise.
We do not want to imply that all calories consumed must be expended with physical
activity to maintain a healthy energy balance. Our objective was to provide a better
format than simple calorie counts for contextualizing energy content of different
foods. Through this study, we hoped to gather qualitative data to guide effective
application of our labels either as an addition to or replacement for numerical calorie
information.

Conclusions

Limitations of the current study include limited generalizability of our findings,
and inability of the current study to predict how our labels might affect real world
behavior. We used convenience sampling to recruit an ethnically and socioeconomically
diverse study population but recruited in a limited geographic area and excluded participants
under 25 years of age. The vast majority (90%) of our study population had adequate
health literacy, which makes it difficult to predict how those with lower health literacy,
almost 50% of the general population, [33] would use the labels.

In using focus groups, our study goal was not to provide a quantitative assessment
of these labels. Focus groups are a valuable tool for gathering the breadth of opinions
on a subject [34]. Through open-ended questioning, we were able to gather verbatim interpretation of
various labels without prompting and report conveyed meaning. This helped us improve
the label design and create labels that could be widely understood. However, we did
not test label performance or compare our labels to other formats. We are interested
in designing a physical activity equivalent label to compliment or replace calorie
information on quick-service restaurant menus, but our study does not provide sufficient
information on whether or how consumers might use physical activity equivalent labels.
Moreover, it cannot predict whether these labels positively affect consumer choice
behavior or the prevalence of overweight and obesity.

Our labels present a universally applicable physical activity equivalent for caloric
information and do not account for several variables—age, gender, body weight—important
to determining the actual metabolic results for an individual trying to use the label.
Thus the labels may be overly simplistic and could cause confusion for consumers trying
to offset caloric intake with physical activity.

Future studies should test these labels with a wider population that can provide both
qualitative and quantitative data. A companion study is currently in press [35] in which we used a web-based survey to randomize participants to different label
types and test performance with simulated food choices. Using this data, we anticipate
finalizing adaptations to the label format and performing laboratory-based, randomized
studies of consumer behavior using menus with a variety of label types, like those
that have been used to test calorie menu labels [14,16]. Because laboratory-based studies are poorly generalizable to real world behavior,
large-scale studies implementing different label types in quick-service restaurants
will be necessary to fully measure their effects on the prevalence of overweight and
obesity. Such studies would require governmental and industry participation.

Public health advocates and policy-makers need more and better information as they
promote and implement various tools to combat overweight and obesity. Calorie menu
labeling is an attractive option in that it provides information a majority of consumers
want [25,36]. To have a positive effect on the prevalence of obesity, consumers would have to
respond to new menu labels by purchasing and consuming fewer calories, eating more
at home, patronizing restaurants that provide lower-calorie options, or exercising.
The food service industry might also respond, as it did when the government expanded
nutrition labeling laws on packaged products in the 1990s, by improving the nutritional
profile of its offerings [17]. Early studies of calorie menu labels indicate they may not be having their intended
effect [5,6].

Physical activity equivalent labels have the potential to be more persuasive than
calorie information alone because they contextualize the information in familiar terms.
Labels that make it easier to compare items on a menu facilitate better choices. Our
label is designed to help people eat less and also encourage them to move more, a
more complete approach to combat overweight and obesity than labels that only address
nutritional content. More research is needed to establish whether consumers can and
will apply such information in a way that leads to healthier living.

Appendix 1: Focus group guide

Project: Design nutrition labels that use physical activity to contextualize energy
information. For example, we will have a picture of a running person with a statement
“You would have to run 50 minutes to burn the calories in this sandwich.” The focus
group will be used to get consumer reactions to label design, refine the design, and
get an idea of whether consumers understand the labels.

Questions:

1. Icebreaker: Where do you get your groceries?

2. How do you pick what food you eat?

3. How do you decide what foods are healthy or nutritious?

4. Think back to the last time you were at a fast food restaurant like (McDonalds,
Burger King or Subway) ordering from the menu. How did you decide what to order? At
this point, we will distribute the labels to the group. We may have a large poster
of the labels so that we can talk about them. We also may put them on actual packaged
food items. We will include several of our exercise label formats and one modeled
after current calorie labels on menus.

5. a. Describe what symbol A means.

b. Describe what symbol B means.

c. Describe what symbol C means.

6. Would you change anything on this label?

-Which label do you like better? SHOW EXAMPLE OF LABEL THAT EXPRESSES ENERGY INFORMATION
IN DISTANCE (MILEAGE) RATHER THAN TIME

-Which label do you like better? SHOW EXAMPLE OF LABEL WITH DIFFERENT FONT

-Which label do you like better? SHOW EXAMPLE OF LABEL WITH DIFFERENT PICTURE

-Which label do you like better? SHOW EXAMPLE OF LABEL THAT HAS AVERAGE RECOMMENDED
DAILY EXERCISE

7. Imagine yourself back at a fast food restaurant. If you had one of these labels
in front of you, how would it affect what you ordered?

8 Imagine these labels on a cereal box at a grocery store. What label or information
would help you choose between types of cereal?

9. We wanted you to help us evaluate and improve nutrition labels so that they are
more useful for consumers. Do you have any ideas for nutrition labels that you would
like to see? Is there anything about nutrition labels that you have not had a chance
to say?

Appendix 2: Sample calculations for menu labels

Example: Subway Ham Sandwich = 290 kcal

Energy expenditure for walking labels:

Walking at 30 min/mile pace = 3.2 kcal/min (for 160 lbs adult)

290 kcal/ 3.2 kcal/min = 91 min = 1.5 hrs

91 min/ 30 min/mile = 3 miles

Energy expenditure for running labels:

Running at 10 min/mile pace = 12.8 kcal/min (for 160 lbs adult)

290 kcal/ 12.8 kcal/min = 23 min = 0.4 hrs

23 min/ 10 min/mile = 2.3 miles

Competing interests

The authors declare that they have no competing interests or financial disclosures.

Authors’ contributions

JS designed the focus group format, facilitated the focus groups, took the lead on
transcript analysis, and prepared the manuscript. SD helped facilitate focus groups,
assisted in transcription, assisted in analysis, and edited the manuscript. DB helped
facilitate focus groups, helped with label design and to identify key background literature,
and edited the manuscript. PM helped with analysis and edited the manuscript. AV assisted
in designing the focus group format, helped with label design, guided analysis and
edited the manuscript. All authors read and approved the final manuscript.

Authors’ information

Author Jonas J Swartz was a student at the University of North Carolina Gillings School
of Public Health at during the time this research was conducted.

Acknowledgements

This research was supported by funding from the University Research Council at the
University of North Carolina. The authors wish to thank Clay Braxton for illustration
and design work. The authors also wish to thank the graphic design office at the Office
of Information Services at the University of North Carolina who did illustration and
design work. Support for open access publication was provided by The University of
North Carolina at Chapel Hill’s University Research Council and the University of
North Carolina at Chapel Hill’s Libraries.

Larson N, Story M: Menu Labeling: Does Providing Nutrition Information at the Point of Purchase Affect
Consumer Behavior. A research synthesis. : Healthy Eating Research national program. Robert Wood Johnson Foundation; 2009.